chronic pain management Flashcards
ACUTE PAIN TRANSFORMATION
- ACUTE PAIN CAN BECOME CHRONIC IF IT LASTS
MORE THAN 6 MONTHS OR THE TIME IT WOULD
TAKE CONNECTIVE TISSUE TO HEAL
TEMPOROMANDIBULAR DISORDERS
* MANY ARE?
* CHRONIC TMD PAIN SYNDROMES LAST MORE THAN?
- MANY ARE MILD AND SELF-LIMITING
- CHRONIC TMD PAIN SYNDROMES LAST MORE THAN 6 MONTHS
what psychiatric symptoms AND CHRONIC MUSCULOSKELETAL PAIN HAVE
A DIRECT CORRELATION?
DEPRESSIVE SYMPTOMS AND CHRONIC MUSCULOSKELETAL PAIN HAVE
A DIRECT CORRELATION
what psychiatric dx INCREASES THE PATIENT’S SELF REPORTING OF PAIN
ESPECIALLY SKELETAL MUSCLE PAIN
ANXIETY INCREASES THE PATIENT’S SELF REPORTING OF PAIN
ESPECIALLY SKELETAL MUSCLE PAIN
approach for tx TMD should be single or multimodal
MULTI-MODALITY APPROACH IS BEST FOR MANAGEMENT OF TEMPOROMANDIBULAR
DISORDERS
* MEDICATIONS
* SPLINT THERAPY
* PHYSICAL THERAPY
* ACCUPUNCTURE
* PSYCHOTHERAPY
* SURGERY
CHRONIC OVERLAPPING PAIN CONDITIONS (COPCS)
COMMON CO-EXISTING PAIN CONDITIONS:
- TMD
- FIBROMYALGIA
- HEADACHES (MIGRAINES, TENSION-TYPE, AND TAC’S)
- IRRITABLE BOWEL SYNDROME (IBS)
team for tx TMD?
TEAM APPROACH FOR CHRONIC PAIN HAS BEST TREATMENT OUTCOME
- INVOLVE MULTI-SPECIALTIES SUCH AS:
- OROFACIAL PAIN
- PHYSICAL THERAPY
- PAIN PSYCHOLOGIST
- RHEUMATOLOGIST
- NEUROLOGIST
DIAGNOSES WITH SIMILAR SYMPTOMS
CAUSE HEAD & FACIAL PAIN:
MIGRAINE HEADACHE
· TENSION HEADACHE
* TRIGEMINAL AUTONOMIC CEPHALGIAS (TAC’S)
· TEMPORAL ARTERITIS
· EAR INFECTION
· SINUS INFECTION OR TUMORS
· TOOTH INFECTION
· JAW JOINT SPRAIN
· NEURALGIA
· JAW JOINT DISK DISPLACEMENT *
DIAGNOSES WITH SIMILAR SYMPTOMS
CAN CAUSE MALOCCLUSION:
- ORAL CANCER
· JAW JOINT TUMORS (I.E. OSTEOCHONDROMA)
· DENTAL MALOCCLUSION ESPECIALLY SECONDARY TO OSTEOARTHRITIS OR RHEUMATOID ARTHRITIS - FACIAL MUSCLE SPASM
JAW FRACTURE
pain tx flowchart: mild and moderate vs severe
ACETAMINOPHEN
* other names
* NO effect?
* bleeding?
* OVERDOSE:
* MAX DAILY DOSE:
* CHRONIC PAIN
ACETAMINOPHEN
* PARACETAMOL (GENERIC IN SOME FOREIGN COUNTRIES)
* APAP (ACETYL-PARA-AMINOPHENOL)
* NO ANTI-INFLAMMATORY EFFECTS
* MINIMAL INCREASED RISK OF BLEEDING
* OVERDOSE: HEPATOTOXICITY
* MAX DAILY DOSE: 4000 MG PER DAY IN DIVIDED DOSES EXCEPT
* CHRONIC PAIN -3000 MG PER DAY IN DIVIDED DOSES 11
ACETAMINOPHEN dose forms
acetaminophen combined with opioids
HYDROCODONE-ACETAMINOPHEN
* NORCO 5MG, 7.5MG, 10MG/325MG
* VICODIN 5MG, 7.5MG, 10MG/300MG
OXYCODONE WITH ACETAMINOPHEN
* ENDOCET, ROXICET: 5MG, 7.5MG, 10MG/ 325MG
* PERCOCET: 5MG, 7.5MG, 10MG/ 325MG
warning when using acetaminophen combined with opioids
WATCH FOR CONCURRENT MEDICATIONS CONTAINING ACETAMINOPHEN
ESPECIALLY OTC PRODUCTS SUCH AS SLEEP AIDS
acetaminophen COMBINATION WITH CODEINE
codiene increases by 2
acetaminophin with tramadol
ULTRACET
* ACETAMINOPHEN/TRAMADOL
* 320MG/37.5MG
Advantages of Long-acting Opioids
- MORE CONSISTENT ANALGESIA
- FEWER ADVERSE EFFECTS
- MORE TOLERANCE TO ADVERSE EFFECTS
- BETTER SLEEP ➔ BETTER DAYTIME FUNCTION
- LESS EUPHORIA, ADDICTION, DIVERSION
OTC PRODUCTS CONTAINING ACETAMINOPHEN
Excedrin Extra strength, Excedrin Migraine
Acetaminophen/ Aspirin/ Caffeine
* 250mg/ 250mg/65mg
Comtrex
Acetaminophen/Dextromethorphan/ Phenylephrine
* 325mg/ 10mg/ 5mg
NON-STEROIDAL ANTI-INFLAMMATORY DRUGS
(NSAIDS) of interest
- ASPIRIN
- IBUPROFEN
- NAPROXEN
- MELOXICAM
- CELECOXIB
NSAIDS effects
- ANTI-INFLAMMATORY EFFECTS
- ANALGESIC EFFECTS
- ANTIPYRETIC EFFECTS
nsaids effects at low doses
- Antipyretic effects
- Analgesic effects
nsaids effects at high doses
- Antipyretic effects
- Analgesic effects
- More anti-inflammatory effects besides mentioned effects
- IBUPROFEN (MOTRIN®, ADVIL®)
- OTC dose?
- RX doses?
- MAX DOSE:
- TOXICITY:
- OTC 200MG
- RX 400MG, 600MG, 800MG
- MAX DOSE: 3200 MG PER DAY IN DIVIDED DOSES
- TOXICITY: GI ULCER
TO REACH ANTI-INFLAMMATORY EFFECTS of nsaids MUST USE how much?
TO REACH ANTI-INFLAMMATORY EFFECTS MUST USE 1800MG- 3200MG/DAY IN DIVIDED DOSES
IBU with opioids
Oxycodone/ Ibuprofen
* 5mg/ 400mg
* Maximum of 4 tablets/day in divided doses
Hydrocodone/ Ibuprofen
* 2.5mg, 5mg, 7.5mg, 10mg/ 200mg
* Maximum of 5 tablets /day in divided doses
long lasting nsaids
naproxen and celecoxib
NAPROXEN (ALEVE® 220MG OTC)
* MAX DAILY DOSE:
* TOXICITY:
* COMBINATION WITH PPI ?
- MAX DAILY DOSE: 1500 MG PER DAY IN DIVIDED
DOSES - TOXICITY: GI ULCER
- COMBINATION WITH PPI ESOMEPRAZOLE TO
MINIMIZE THE GI DAMAGE (BRAND NAME VIMOVO®)
CELECOXIB (CELEBREX®)
* moa
* dose
* AVOID IF PATIENT HAS?
- SELECTIVE COX 2 INHIBITOR
- 100MG OR 200 MG TWICE DAILY
- AVOID IF PATIENT HAS SULFA ALLERGY
ACETAMINOPHEN,
NSAIDS ceiling effect
These analgesics have ceiling effect
* Has a limit in relieving the pain
* Above the limit
* No more analgesic effect
* More toxicity
ACETAMINOPHEN,
NSAIDS tolerence and dependence
No tolerance or dependence happen with
these analgesics
how to lower GI ADRs of nsaids
Take NSAIDs with food to lower GI ADRs
